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Value- added TNC Activities Build caseload over three months Discharge patients from floor in collaboration with inpatient team Proactive calls to patient before first visit Baseline assessment with rest of care team including:  Learning needs  Presence of anxiety or depression – Stop D tool  Falls risk and cognitive assessment (65 and older) TUG and MoCA With patient and family, develop care plan Follow up on missed care Facilitate referral to community physician at 3 months (parallel follow-up until first year visit) Follow patients for six months total and then rotate back to “pool”  Proactive, coordinated care that is based on a caring relationship with the patient and family

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Transplant Nurse Coordinator New Model 13 Two Nurses Closely Follow Patients for Three Months months123 case per dyadcase labs/day16.53345 per TNC81723 calls/actions1211 per TNC655 Clinic Visits * average all days not the same1213 per TNC677 number of patients2682138 per TNC134169 Note one week per month would be inpt - dyad mate would cover all pts